Roles and Responsibilities
Culture Change
Quality Improvement Approach
  • Build integration strategies into benchmarks for best practices in chronic disease management
    Vertical and horizontal clinical integration strategies, as discussed in the “Chronic disease management” section of this curriculum, provide a system of targeted interventions. The outcomes of these intervention strategies can be tracked in clinical, fiscal, and logistical factors to determine if adjustments are needed. Outcome tracking for clinical conditions may be specific to a particular patient population, such as reducing PHQ-9 scores of all patients with a diagnosis of depression. Or the reduced utilization of pain medications as it relates to the provision of BHP services focused on helping patients manage their chronic condition. Model fidelity may be evaluated by the level of penetration the BHP has within the total population of the practice. This level may be increased by adjusting the model to one that is more horizontally focused. Model fidelity can also be based on PCP satisfaction surveys. Other items to consider for quality improvement are: the average number of visits per patient, patient satisfaction survey results, and the range of problems addressed (Robinson and Reiter, 2007).

    Resource:
    Annotated bibliography: Robinson and Reiter, 2007, Behavioral Consultation and Primary Care: a Guide to Integrating Services, Chapter 15, “Evaluating your service”
Training Staff
  • Resources:
  • Certification Programs
    Graduate programs in primary care psychology prepare BHPs to work in the primary care setting, however, most graduate counseling, social work, and psychology programs do not typically prepare graduates for this working environment. Certification and certificate programs are aimed at training licensed clinical professionals to function successfully as BHPs in primary care settings by augmenting their skill-sets.

    The Department of Family Medicine and Community Health at the University of Massachusetts (UMASS) began the Certificate Program in Primary Care Behavioral Health in January, 2007 under the leadership of Dr. Alexander “Sandy” Blount. The program consists of 36 hours of didactic and interactive training.

    The Mountain Area Health Education Center borrowed the curriculum outline from UMASS with permission from Dr. Blount and made additions/adjustments to incorporate their experience in IC clinical programming, teaching, technical assistance, and developments in IC in the state of North Carolina. The program may be repeated in the near future.
 
Sample Job Descriptions

Resources:

 
Hiring BH Staff
  • Factors to consider
    Hiring the right BHP for integrated care will require careful thought. Primary care or other medical practices that are starting a new behavioral health program will likely have little experience in evaluating skill-sets needed for the job. The practice leaders are likely to be comfortable evaluating candidates to fill common roles in the practice, however, they may not feel as comfortable when attempting to differentiate between applicants for behavioral health positions. If the target of the new program is to co-locate a mental health/substance abuse specialist to provide a co-located and separate service in a primary care environment, then the standard skill-sets of a traditionally trained mental health/substance abuse therapist will be adequate. Generally, the service provided will be an evidence-based traditional one hour therapy session, and groups. The first section of this curriculum addresses some of the pros and cons of this model. In integrated behavioral health models, the BHP will need additional skill-sets such as, but not limited to, the ability to provide brief consults to medial providers, work through administrative and workflow issues to build the new program, be proactive and flexible to deliver evidence-based approaches in many formats including short time frames, focus on the patient’s chief complaint (Pomerantz, Corson, & Detzer, 2009), knowledge of medical conditions and how to address them behaviorally, and teaching other providers how to use skills such as motivational interviewing.

  • Does professional discipline matter?
    In general, clinical perspectives, the professional discipline of the BHP, should not matter as long as the provider has received the appropriate training and can show competency in all the recommended behavioral health, mental health, substance abuse and medical areas described in the literature and in this curriculum. Gatchel and Oordt (2003) favor the selection of psychologists for BHP roles and place caution in assuming that the training and expertise of applicants will be the same across different behavioral health disciplines and degrees. Within these groups, training that would best serve a BHP in an integrated care setting will vary and one’s professional discipline and level of degree do not account for the individual difference between BHPs (Cummings, et.al., 2001). The professional discipline of the BHP may raise fiscal concerns, such as needing to pay doctoral level providers more. In primary care settings where all ages are served, the BHP’s reimbursement for services may be limited due to insurance limitations that exclude certain disciplines. A good example of this is with Medicare, which does yet not allow Licensed Professional Counselors (LPCs) to directly enroll as a provider. LPCs who encounter Medicare patients in North Carolina will need to serve them “Incident To” a physician provider while meeting the requirements of this billing scenario. This would not be the case in a pediatric setting where the need to bill Medicare is almost nonexistent. Services performed in an “Incident To” fashion succeed in promoting integration due to the communication and documentation required between providers. However, there are times when the BHP may need to bill under his/her own provider number. When a patient’s initial Medicaid or Medicare behavioral health benefit is exhausted, usually after the 8th encounter for adults who may have already been seen elsewhere, the BHP will need to attain authorization for additional sessions. These sessions will be authorized to the BHP and cannot be billed “Incident To” the physician. It is important to note that integrated settings that focus on brief encounters and engagements with the BHP may not be concerned with the details associated with authorization for additional sessions and would routinely refer patients with higher needs to specialty mental/substance abuse services. An additional benefit of billing “Incident To” the physician is realized when the BHP is a masters prepared clinician. In this case the services rendered “Incident To” the physician will be reimbursed at the MD/PhD level.

    Resource:
    LCD for Psychological Services Coverage Under the “Incident To” Provision for Physicians and Non-physicians

  • What past experience is useful?
    Graduate training and post-graduate training classes/programs that focus on integrated primary care will provide BHPs with training for the primary care environment. BHPs who have worked in medical settings such as hospitals, emergency rooms, and crisis clinics will have had experiences in fast-paced clinical settings where brief interactions and consultations are frequent. Medical social workers or social workers who have had training in medical social work principals will have skill-sets that can be advantageous (Cummings, et al., 2001).

  • Interviewing questions
    As described above, the characteristics of a successful BHP require many skill-sets and medical practices may not be accustomed to interviewing and hiring this type of clinician. In chapter 3, “A Mission and Job Description,” Robinson and Reiter (2007) have supplied a list of questions for interviews for BHP applicants.

    Resource:
    Annotated bibliography: Robinson and Reiter, 2007, Behavioral Consultation and Primary Care: a Guide to Integrating Services, Chapter 3, “A Mission and Job Description”
 
Core Competencies for Behavioral Health Provider Staff
  • Understanding the medical model/ practice flow for patient care
    “Primary care is the provision of first contact, person-focused ongoing care over time that meets the health-related needs of people, referring only those too uncommon to maintain competence, and coordinates care when people receive services at other levels of care.” (Starfield, 2005, slide 5)

    Primary care is a population-focused service that serves as a medical home for most individuals. Integrated Primary Care Behavioral Health requires the BHP to function like a primary care provider in terms of working in shorter time frames and offering concrete brief interventions focused on increasing patient functionality (O’Donohue et al., 2005; Hunter, et.al., 2009).

  • Use of brief interventions: (15 – 30) minute and “One-Shot” encounters
    Brief interventions, including “One Shot” encounters discussed in the next segment, are an integral part of behavioral health IC programming. It is well documented that psychotherapy patients average 4 to 6 sessions and that 50% of patients discontinue services without communicating with their therapist. Primary care patients are likely to identify with services provided in durations that are most similar to the format that they are receiving from their PCP. Brief interventions using bite-sized evidenced-based approaches have shown clinical outcomes that are comparable to those found in specialty services (O’Donohue, et al., 2005). One-Shot encounters work best when they are presented as part of a comprehensive prevention program.

  • Chronic disease management
    The management of chronic disease is an area in which behavioral health services can be particularly helpful. BHPs can assist PCPs by vertically integrating their services in a planned algorithm-like manner for targeted conditions or horizontally, as needed, to address the behavioral health aspects of any chronic condition. BHPs should avoid providing psychotherapy for chronic physical health conditions (Hunter, et al, 2009) and focus rather on functionality and adherence to recommended treatments. Robinson and Reiter (2007) discuss the types of interventions BHPs can provide for chronic conditions such as using motivational interviewing, focusing on small, well-defined behavior changes, functioning as a team member with the PCP, offering consults over a period of time, and promoting the development of group care clinics, which can include the BHP’s services. Common chronic conditions such as diabetes, obesity, and chronic pain may be treated over time as the PCP and BHP work together to address the patient’s goals (Hunter, et al., 2009).

  • Medical literacy
    BHPs should familiarize themselves with common medical terminology, best practice guidelines, and medications (Robinson & Reiter, 2007). In order to assist patients in improving their behavioral self-care related to their health condition, BHPs may need to spend significant time updating their knowledge-base Starting with the most common health conditions in order to feel comfortable with the largest portion of the primary care population is sensible. BHPs should, however, stay within the ethical boundaries of competence and roles and avoid giving medical advice (Gatchel & Oordt, 2003), such as suggesting that a patient adjusts their medications. Alternatively, it is appropriate to suggest that the patient should consider discussing their concerns about their medication with their PCP. The PDR Drug Guide for Mental Health Professionals is a suggested resource for BHPs (Robinson and Reiter (2007), and is common tool used in specialty behavioral health settings to reference the qualities of all medications.

    Resource:
    Community Care of North Carolina: Tools to Help Providers and Patients Manage Care.

  • Case Management skills
    Case management is a skill area in which a BHP may need to become more familiar. There can be numerous behavioral health case management duties and the BHP will have to learn how to manage them along with their other duties. One function the BHP may need to take on is being the knowledgeable liaison to the local specialty mental health and substance abuse provider community. In this role, the BHP may do more than make referrals for patients with more severe mental health needs, but he/she may also provide some monitoring of patients who have been referred out of the practice. The details of any medications prescribed by other physicians/psychiatrists should be communicated back to the PCP for continuity and to avoid contraindications. Patients who need extensive case management may concurrently need more extensive services, which may require a referral to a specialty mental health and/or substance abuse provider. BHPs will need to balance the degree to which they are able to provide case management services with the provision of patient care. Often, these case management functions are not reimbursable, a factor that should be considered when referencing revenue and productivity expectations. Some of the functions described above may already be the duty of another practice employee’s position, which should be considered when assigning functions to the BHP. It is important to create a BHP position that has a balance in the services provided. Some practices employ care managers or have access to care managers and case managers, adding to the resources available to the practice and relieving the BHP of some of these functions.

  • Brief screening, intervention, and referral approach
    BHPs working in primary care settings will participate in clinical routines involving screening, brief interventions and making referrals when appropriate. This will allow BHPs to provide focused interventions to a large number of patients rather than comprehensive care to a small population that can be referred to specialty services (Hunter, et.al, 2009). This model of practice requires that the BHP has dependable referral sources. The SBIRT model, which is frequently used with substance abuse conditions, provides an example of the process in a diagram (see page 4 in the linked document).

  • How to be a consultant to PC staff
    Some BHPs provide consultation to PCPs as a formal part of their job description. Consultations may consist of curb-side consults, case consultations, and patient interactions. Patient consultations can be focused on clarifying the problem, conducting a functional assessment, summarizing your understanding of the problem, listing possible change-plan options, and starting a behavioral change-plan. PCPs will appreciate the services provided and will anticipate feedback from the BHP in a brief and prompt format (Hunter, et.al., 2009).

  • Familiarity with psychopharmacological interventions for BH treatments
    BHPs in IC settings will need knowledge of psychotropic medications when working with patients and providers. Medication benefits, adherence, side effects, qualities, regimens, indications, and developments are commonplace in IC settings. BHPs may be relied upon in-between medical visits to communicate with patients, who have been referred to them for therapy, about their medications. Informal or formal care management activities can be employed during these interactions. The BHP can alert PCPs when patients are having undesirable side effects or a lack of improvement. As stated earlier in the “Medical Literacy” section, BHPs will also benefit from cross-training on medications used to address common physical health conditions (Robinson and Reiter, 2007).

  • Crisis Intervention
    The BHP will be a resource within the practice for crisis intervention services. It is important for the BHP to be comfortable in assessing for suicidal and homicidal ideations and in knowing how to follow-through with the procedures to involuntarily commit a patient who is in need of further evaluation and possible hospitalization. Depending on their past work experience, BHPs may need additional training in this area. The “Documentation” section of this curriculum has information on the proper involuntary commitment forms to use in North Carolina. Note that procedures and forms vary from state to state.
 
Core Competencies for PC staff
  • Bio-psychosocial model
    “Integrated primary care is a service that combines medical and behavioral health services to more fully address the spectrum of problems that patients bring to their primary medical care providers. It allows patients to feel that, for almost any problem, they have come to the right place” (Blount, 1998, p. 1). BHPs working in integrated settings must be comfortable offering assistance, at times without a great deal of patient information, and should develop comfort offering this assistance for any condition to assist the provider team and to provide support for the behavioral health components inherent in medical conditions. The model is based on the widely accepted concept that our mind and body are connected. ICARE 101 supports the rational for a bio-psychosocial model of integration and explains the relationships and correlations between physical and mental health conditions in terms of their prevalence, effects on utilization, healthcare costs, and lack of adherence to treatment.

    Resource:
    Reasons to integrate care and the ICARE 101 presentation
  • How to use behavioral health consultation and the referral process
    BHPs providing consult services as their only role to patients and PCPs should function like other providers who are consulting within their field of specialty. The goal here is to see “all comers,” to assess any behavioral health issue they may have, and to make suggestions for appropriate types of treatment and referrals. BHPs in these roles may see 14 to 18 patients a day. Alternatively, BHPs who are consulting in a primary care behavioral health model will see fewer patients as they provide consultation and brief treatment interventions throughout the day. These BHPs may need to refer patients for more extensive follow-up and for psychotherapy and specialty services (O’Donohue, et al., 2005). PCPs will need to have access to an efficient way to alert the BHP when a consult is needed. Some clinics use paging systems or cell phones and changeable signage outside exam room to signal providers. Feedback from the BHP to PCP should be brief, succinct, and limited to about 60 seconds unless the PCP asks for more information or clarification. BHPs should avoid using psychological jargon when it is unnecessary (Hunter et al., 2009).

  • Using Evidenced-Based Medicine for BHPs
    PCPs often focus their clinical interventions on evidenced-based care, which includes strategies and treatment for behavioral health. PCPs rely on information from their professional organizations to guide their clinical practice (Hunter, et al., 2009). BHPs working in medical settings should be aware of developments in these areas so that they may effectively collaborate with PCPs. Similarly, should BHPs also provide evidenced-based interventions to their patients. For example, Cognitive Behavior Therapy (CBT) has been shown to be effective for adult depression. O’Donahue, et.al. (2005, table 2.2) discusses how common evidence-based psychotherapies can be adapted for use in the fast pace of a primary care environment.

    Resources:
  • Incorporating behavioral health interventions into practice
    Behavioral health interventions can be integrated horizontally or vertically. Horizontal integration consists of interventions and services that are focused on serving “all comers” (O’Donahue, et.al., 2005) and are followed out via consultation and brief treatment. Examples of horizontal integration are providing service in the form patient education and brief focused interventions for any condition. Vertical integration interventions focus on chronic conditions so that the service interactions by all involved providers are outlined to increase efficiency and reinforce treatment goals, while maximizing the specialty expertise of all providers. The targeted conditions chosen for vertical integration should be tailored to the pace of primary care and are ideally those that will respond to evidence-based behavioral health therapies (O’Donahue, et.al., 2005). Some common conditions targeted for vertical integration are depression, diabetes, and anxiety.

  • Patient-first focus including patient engagement
    Although PCPs and BHPs may have their own concerns about a patient’s condition or the need to follow-up on an historical item it, is paramount to honor and address the patient’s chief complaint that led him/her to making their visit to the clinic. Addressing the patient’s chief complaint will increase the likelihood of successfully addressing the aforementioned concerns of providers. Providers will be extending respect for the patient’s pressing concern, while strengthening rapport, and engaging the patient in making decisions about his/her own treatment.

  • Develop “warm hand-off” technique
    Overtime, PCPs will perfect their patient hand-off to the BHP. As they work together and the PCP learns more about the skills of the BHP, he or she will begin to rely on behavioral health interventions. In this way, the process will become seamless. The hand-off serves as an introduction, during which PCPs are in a position to extend the rapport they have with their patient onto the BHP. The PCP achieves this by explaining that the BHP is someone with whom the PCP frequently collaborates and that the BHP has skills that meet the patient’s identified needs (Robinson and Reiter, 2007).

    Sample statement by PCP: “Our clinic is fortunate to have an onsite behavioral health provider who specializes in working with patients who are experiencing difficulties with _____ (use patient’s words such as stress and worry). She is our consultant and we work together as a team to address many types of conditions. I would like to introduce you to her. Would that be ok? Her name is _____ .” Invite the BHP into the room (if available) and explain concern, in the patient's words, and in front of the patient. This provides the patient with an opportunity to see the teamwork and communication between providers, correct any misinformation, and participate in the decisions made about their treatment (Gatchel and Oordt, 2003). In the sample above, the terminology used to identify the BHP can vary by clinic. Some use Behavioral Health Consultant (BHC). See video resource below for more information.


  • Working as a team member
    BHPs can enhance their effectiveness and degree of integration by being a true team member in the practice. It is important for the BHP to reinforce his/her collaborative role during interactions with patients and providers. Robinson and Reiter (2007, figure 7.1), have a sample script to use when working with patients. It illustrates the BHPs role in the patient’s overall care while reinforcing collaboration among all involved. BHPs can improve their collaboration with providers for the common purpose of improving care by asking PCPs to collaborate on their cases, providing information on community resources that need to be identified, participating in provider and clinic staff meetings, discussing communication routines for better results, using common terminology (Hunter et al., 2009). One caveat of this collaborative relationship is that the patient may express concerns about the BHP to the PCP or vice versa. BHPs should be approachable and encourage open communication with both patients and PCPs (Seaburn, Lorenz, Gunn, Gawinski, & Mauksch, 1996).

  • Conduct “shared” appointments as needed
    BHPs and PCPs can conduct shared appointments to address the needs of patients with complicated conditions or difficulties managing their conditions. The BHP can assist in many ways including: clarifying diagnosis of a mental health or substance abuse condition, moderating with difficult patients, and formulating behavioral goals to complement the PCPs plan of care.

    Resources:
  • Develop targeted caseloads for BH interventions that meet the needs of the practice
    BHPs can interview PCPs and other practice staff members to determine which targeted areas would be most helpful, basing them on common patient conditions and high utilization. The BHP’s interventions can be vertically integrated as discussed earlier, to address conditions such as depression and anxiety. Or the BHP’s interventions may be horizontally integrated in brief encounters for “all comers” (O’Donohue, et al, 2005). Patients receiving horizontally integrated services are less likely to be considered as part of the BHP’s caseload for follow-up.